Neurological Procedure Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record #: ______________

Procedure Information

Proposed Procedure: ____________________________________________ Side/Location (if applicable): ____________________________________

Consent Declaration

I, _________________________, hereby authorize Dr. _________________________ and/or associates to perform the following procedure(s):

Understanding of Procedure

I confirm that I have been informed of and understand:

• The nature and purpose of the procedure
• Expected benefits and likelihood of success
• Possible alternatives to the procedure
• Relevant risks and possible complications
• The recovery process and follow-up care requirements

Specific Risks Discussed

• Infection
• Bleeding
• Neurological complications including:
  • Weakness
  • Numbness
  • Speech difficulties
  • Vision changes
  • Memory problems
  • Seizures
• Pain or discomfort
• Need for additional procedures

Patient Acknowledgments

• I have had the opportunity to ask questions
• I understand that no guarantees have been made regarding the outcome
• I am aware that unforeseen conditions may require additional or different procedures
• I authorize the disposal of any removed tissues/materials

Signatures

Patient/Legal Guardian: _________________________ Date: ___________

Witness: _____________________________________ Date: ___________

Physician: ____________________________________ Date: ___________

This form is part of your permanent medical record